Prevalence of elective cosmetic surgery and its relationship with socioeconomic and mental health: A cross‐sectional study in west of Iran

Abstract Background and Aims The aim of this study was to investigate the prevalence and desire towards performing elective cosmetic surgery and its relationship with socioeconomic, mental, and spiritual health in Sanandaj, the capital of Kurdistan province in the west of Iran. Methods This cross‐sectional descriptive‐analytical study was performed on 492 subjects in Sanandaj using multistage sampling method. Data collection tools included two checklists and two questionnaires. Data analysis was performed using the Chi‐square test and multiple logistics regression model by the help of SPSS software version 20. Results The mean (standard deviation) age of participants was 32.58 (9.67) years. The prevalence of cosmetic surgery and the desire to perform it were 12.8% (n = 63) and 19.1% (n = 94), respectively. The most common type of cosmetic surgery was rhinoplasty with 5.5% (n = 27). The prevalence of symptoms of mental disorders among people with cosmetic surgery and people willing to perform cosmetic surgery was significantly higher than all subjects (p < 0.001). Female gender (odds ratio [OR] = 1.98; 95% confidence interval [CI]: 1.06–3.68) and having mild (OR = 3.01 95% CI: 1.06–3.68) and moderate to severe symptoms of mental disorder (OR = 7.59; 95% CI: 3.90–14.75) were among the influential variables on performing cosmetic surgery. Conclusion Both the prevalence and desire towards performing cosmetic surgery are high in Sanandaj and this needs the attention of health policy makers. Designing targeted interventions with an emphasis on the findings of this study is proposed to reduce these practices.


| INTRODUCTION
Cosmetic surgery is defined as an optional invasive procedure to change and correct the shape of the body in the absence of a specific disease, injury, or birth defect. 1 A common defense of cosmetic procedures is to help improve self-confidence and thus allow the patient to live a happier life. 2 Statistics show that the number of cosmetic surgeries in the world is increasing every year compared to the previous year. 3 Breast augmentation, liposuction, blepharoplasty, rhinoplasty, abdominoplasty, and breast and face lift and breast reduction are the most common cosmetic surgeries in the world. 4 The United States has the largest number of cosmetic surgeries in the world, with more than 2.3 million cosmetic surgeries registered in the country alone in 2020. 5 After the United States, the highest number of cosmetic surgeries are respectively performed in Brazil, Mexico, Germany, India, Japan, Argentina, Russia, Italy, Colombia, South Korea, and Turkey. 6 Cosmetic surgery has become a social value despite its risks and side effects. The increasing importance of appearance in the contemporary world, the effect of fashion, exposure to the media, the spread of social networks, social pressure, encouragement of doctors, advertising, and the cost-effectiveness of cosmetic surgery are among the factors increasing the rate of these operations in the world. [7][8][9][10] Based on the findings of some studies, there is a significant relationship between cosmetic surgery and personality disorders, body dysmorphic disorder, obsessive-compulsive disorder, depression, anxiety, and low self-esteem. 7,[11][12][13][14][15][16] The desire to perform cosmetic surgeries has social, psychological, and cultural roots. 17,18 Cosmetic surgery has its own consequences. In addition to the medical consequences, the economic burden of cosmetic surgery is also a matter of concern. Given that cosmetic surgery can impose risks and physical and psychological complications and a high economic burden on individuals, households, and health systems; therefore, health policymakers and managers must make decisions, design interventions, and evidencebased policies to try to control the unbridled increase of this type of surgery in the community. [19][20][21][22][23] In this regard, in some countries, preoperative psychological assessments are required to diagnose patients who are unsuitable for cosmetic surgery. 24 Although exact statistics on the prevalence of cosmetic surgery in Iran are not available, reports indicate that Iran is one of the top countries in the world in terms of popularity of cosmetic surgery the demand for these surgeries is increasing and these changes have provided a suitable market for plastic surgeons. 7,25 According to unofficial sources, Iran ranks first in the rate of rhinoplasty worldwide. 26 A study conducted in Iran in 2011 reported a 15% prevalence of cosmetic surgery among women. 27 According to the literature, there are very few studies in Iran on the prevalence of cosmetic surgery and the factors influencing the desire towards performing this type of surgery, and there is a deep knowledge gap to provide evidence-based policy in this area. Also, no study has been done in this regard in Kurdistan province. The aim of this study was to investigate the prevalence of cosmetic surgery and the desire to perform it as well as its relationship with mental and spiritual health in Sanandaj, the capital of Kurdistan province in the west of Iran.

| MATERIALS AND METHODS
This cross-sectional descriptive-analytic study was performed on subjects aged 18-49 in Sanandaj, the capital of Kurdistan province in the west of Iran, with a population of 450,000 in 2021.

| Sample size and sampling method
The sample size was determined 493 individuals using the following formula and taking into account p = 0.27 (prevalence of desire to perform cosmetic surgery), 28 d = 0.04 (accuracy rate), and significance level of 95% (Equation 1).
Sampling was performed in several steps. First, among the comprehensive urban health centers of Sanandaj, 15 centers were randomly selected, and among the households covered by each center, 33 households were systematically selected. There was a list of households, their address, and contact number in comprehensive health centers. Then, by referring to the door of the households, questionnaires and checklists were completed by trained interviewers based on self-report for the first person above 18-49 years who was willing and able to participate in the study. Participation in the study was voluntary and written consent was obtained from the individuals. The list, home address, and contact number of the covered households were obtained from the selected centers. In this study, the inclusion criteria were to be between 18 and 49 years old and willing to participate in the study, and the exclusion criteria were to have a mental disability or any disability such that the person is unable to understand and answer the questions in the questionnaire.

| Data collection tools
Data collection tools included two researcher-made checklists and two standard questionnaires. The validity and reliability of the Persian version of this questionnaire have been tested and confirmed in previous studies. The reliability of the questionnaire was reported to be 90% using Cronbach's alpha. 30,31 The Likert scoring method is used in the general health questionnaire. The total score of the four subscales ranges from 0 to 84; the cutoff point for the test is considered to be 23. In other words, individuals whose score is ≥23 are suspected of having reduced mental health and those whose score is <23 are considered healthy. Reduced mental health status is categorized as follows: a score of 23-40 indicates mild symptoms, 41-60 indicates moderate symptoms and 61-80 indicates severe symptoms. For each subscale of mental health, a score of 6 was considered as a cutoff point. Scores ≥6 indicate a suspected disorder and scores <6 indicate good health.
In each of the subscale of mental health, mean scores of 7-11, 12-16, and 17-21 indicate symptoms of mild, moderate, and severe illness, respectively. 32 Questionnaire No. 2 was the spiritual well-being scale of Paloutzian and Ellison. 33 This questionnaire consists of 20 items and two subscales, so 10 items measure religious health and the other 10 items measure existential health. The spiritual health score is the sum of these two subgroups, the range of which is between 20 and 120. The answer to the phrases is graded in a 6-option Likert scale. In this questionnaire, spiritual health is divided into three levels: low , medium , and high (100-120). The validity and reliability of the Persian version of this questionnaire have been tested and confirmed in previous studies. The reliability of the questionnaire was reported to be 82% using Cronbach's alpha. 34

| Data analysis
Descriptive statistical tests including frequency, percentage, mean, and standard deviation were used to describe the data. Also, Chisquare test was used to examine the relationship between demographic and socioeconomic variables, mental and spiritual health with a history of cosmetic surgery (yes/no), and inclination for performing cosmetic surgery (yes/no). The variables in Tables 1   and 3 with a p-value < 0.2 based on univariate analysis were entered into the multiple logistic regression model and the odds ratio and confidence interval were calculated for them. SPSS software version 20 was used to analyze the data

| RESULTS
A total of 493 residents of Sanandaj participated in this study. Most of the respondents were female (56.6%) and had high school education (35.1%). The mean age of the subjects was 32.6 (standard deviation = 9.7) years and for those with the experience of cosmetic surgery was 33.4 (standard deviation = 9.9) years. The prevalence of cosmetic surgery was 12.8% in total (63 people) and 16.5% and 7.9% among men and women, respectively. The prevalence of inclination for performing cosmetic surgery was 19.1% in total and 21.9% and 15.4% among men and women, respectively. Other demographic and economic variables are listed in Table 1.
The most common type of performed cosmetic surgery was rhinoplasty with 5.5% (n = 27). Considering the gender, rhinoplasty with 7.2% (n = 20) and hair transplantation with 3.7% (n = 8) were the most common surgeries among women and men respectively. The most common desire to perform cosmetic surgery was for rhinoplasty with 6.9% (n = 34). Concerning the gender, the most common desire was for rhinoplasty with 7.9% (n = 22) and hair transplantation with 7.5% (n = 16) among women and men, respectively (Table 2). According to Table 3, the prevalence of symptoms of mental disorders among people with the experience of cosmetic surgery and people willing to perform cosmetic surgery in total and by each dimension was significantly higher than the total number of subjects (p < 0.001). The prevalence of people with mild and moderate or severe mental disorders among subjects with a history of cosmetic surgery was 16.8% and 37.5%, respectively, and was 28.4% and 59.7% among those willing to have cosmetic surgery, respectively, which was significantly higher compared to the total number of subjects (p < 0.001). Also, there was a statistically significant difference in prevalence of somatic, anxiety, social dysfunction, and depression symptoms among people with a history of cosmetic surgery compared to people without the experience of performing cosmetic surgery, and among people willing to perform cosmetic surgery compared to those without a desire for such surgeries (p < 0.001) ( Table 3).   27 According to another study in Tehran in 2015, which was conducted among people aged 15-60, 11% of the subjects had performed cosmetic surgery. 35 In general, dissatisfaction with the appearance and the possibility of having cosmetic surgery are more among women than men. 36 The high percentage of surgeries in this study is significant. In countries other than Iran, the ratio of women to men undergoing cosmetic surgery is about 9-1, but in studies conducted in Iran, this ratio is smaller, which indicates a greater desire of men to perform cosmetic surgery. 35 In the present study, this ratio is about 2.
In our study, the prevalence of desire for performing cosmetic surgery was 19.1% in total and 21.9% and 15.4% among men and women, respectively; indicating a high desire for performing cosmetic surgery between both sexes. In recent years, cosmetic surgery in Iran, which is almost entirely provided by the private sector, has become very popular and is increasing. According to studies, the trend toward performing cosmetic surgery is increasing in the world 16,37 and this trend can be attributed to medical advances, increased cosmetic services, increased number of cosmetic surgeons, reduced prices, and expanded media advertisements about cosmetic surgeries. 3,10 In the study of Soheylizad et al. in Iran, 26.7% of students had a desire for performing cosmetic surgery and this desire was twice as high among women. 28 Women are more likely to have cosmetic surgery in other studies. 16,38 The most common type of cosmetic surgery performed by the subjects of the present study was rhinoplasty and the most inclination to perform cosmetic surgery was also for rhinoplasty. By Abbreviations: CI, confidence interval; OR, odds ratio.
Variables of Tables 1 and 3 with a p-value < 0.2 were included in the model. gender, rhinoplasty for women and hair transplantation for men were the most common types of cosmetic surgeries. According to unofficial sources, Iran ranks first in the rate of rhinoplasty worldwide. 26 In Alharethy's study, rhinoplasty was the most common type of surgery in Saudi Arabia. 39 In the United States in 2020, top 5 cosmetic surgical procedures were rhinoplasty, eyelid surgery, facelift, liposuction, and breast augmentation, respectively. 5 According to studies, there are differences in the preferences of different races for the type of cosmetic surgery. 40 Another finding of the present study was that the prevalence of symptoms of mental disorders was significantly higher among people with a history of having cosmetic surgery and for people willing to perform cosmetic surgery. This finding is consistent with the results of other studies. 16,[41][42][43] According to the study of Zahiroddin et al. in Iran, which was conducted as a case-control study, there was no statistically significant difference between the mental health of candidates for performing rhinoplasty and the control group. 44 In the study of Zojaji et al. in Iran, personality disorders were more in the group requesting rhinoplasty than the control group. 45 In another study in Iran, mental disorders (depression, anxiety, aggression, morbidity, obsessive-compulsive disorder, and sensitivity in relationships) were significantly higher in cosmetic surgery applicants than non-applicants. 46 48 Results of other studies have indicated that more women than men undergo cosmetic surgery, which is consistent with the results of the present study. 39,40,49 Studies in the United States and Saudi Arabia have reported a significant relationship between income levels and cosmetic surgery. 39,40 In various studies, having mental and personality disorders has been reported as a predictor of having cosmetic surgery and desire to perform it. 49,50 In our study, the desire towards having cosmetic surgery was only significantly associated with the mental health variable (having symptoms of mental disorder). In a study in Norway, symptoms of depression and anxiety were predictors of a desire to have cosmetic surgery. 49 The results of the study of Soheylizad et al. in Iran are consistent with the findings of our study. In that study, there was no significant relationship between spiritual health and the desire for performing cosmetic surgery. 28 According to a study by Swami et al. in Australia, being female and having a history of performing cosmetic surgery were among the factors influencing the desire to have cosmetic surgery. 50 One of the limitations of this study was the collection of study data through self-reporting. In addition, this study was conducted in the center of Kurdistan province and its results may not be generalizable to other parts of Iran, especially rural areas. Therefore, due to the limitations of the study, one should be careful in interpreting its results.

ACKNOWLEDGMENTS
We would like to thank those who participated in the study. This study was funded by Kurdistan University of Medical Sciences with contract number 1400.181. However, there was no role of the funding body in the study design; collection, analysis, and interpretation of data; writing of the report; or the decision to submit the report for publication.

CONFLICTS OF INTEREST
The authors declare no conflicts of interest.

DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author (Mahdi Rafieemovahhed) upon reasonable request.

ETHICS STATEMENT
This study was approved by ethics committee of Kurdistan University of Medical Sciences with the code IR.MUK.REC.1400.81. Participation in the study was voluntary and written consent was obtained from the participants.